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b u r n s 3 7 ( 2 0 1 1 ) 9 0 5 – 9 0 9
avai lab le at www.sc iencedi rec t .com
journal homepage: www.elsevier.com/locate/burns
The eight-limb modified propeller flap—A safer newtechnique
Husam Hosny a,*, Wael El-Shaer b
a Plastic Surgery Unit, Faculty of Medicine (Kasr El-Eine Hospital), Cairo University, Cairo, Egyptb Plastic Surgery Unit, Bani Suif University, Beni Suef, Egypt
a r t i c l e i n f o
Article history:
Accepted 18 December 2010
Keywords:
Burn contracture
Propeller flap
Central axis flap
Flaps
a b s t r a c t
Introduction: Contracture deformities affecting the flexor aspect of the elbow joint and the
1st web space are not uncommon sequelae of burns. Surgical treatment is contemplated in
those patients with established contractural deformities in whom non-surgical treatment is
ineffective or functional integrity of the joint is at jeopardy. Surgical treatment consists of
incising the scar tissue to release joint contracture and covering the defect that might result
with skin grafting or various tissue flaps. In this work, we used a modification of the
multilobed propeller flap to treat eight patients with contracture deformities.
Materials and methods: Eight patients with contracture deformities of the elbow (five
patients) and 1st web space (three patients) were subjected to release and modified propeller
flap coverage. The modification implies planning eight limbs based on a central axis so that
rotation occurs in 458 instead of 908 in the original propeller flaps.
Results: All patients had acceptable results with complete range of movement regained in
affected joints and no serious complications. Only a case of partial loss of skin graft and
another case with congestion of one lobe were reported, and both were managed conser-
vatively.
Conclusion: The new modification has the advantages of being flexible, can be tailored to best
match the defect so that it can be closed primarily or needs smaller skin grafts, can be used
even when there is much scarring and, finally, the resultant appearance is cosmetically
acceptable with little donor morbidity, if any.
# 2011 Elsevier Ltd and ISBI. All rights reserved.
1. Introduction
The hand and upper extremity are commonly affected in
burns. They are affected in more than 50% of burn cases [1].
Contractural deformities affecting the elbow and hand are
common sequelae of burn injuries. Up to 39% of burns involve
some portion of the hand or upper extremity [2]. Joint
problems and contracture deformities are usually encoun-
tered in those patients, and are attributed to many factors
including acquiring the position of comfort during acute phase
* Corresponding author at: 21 El-Shorta Blds., Maadi Kornish, Cairo 11E-mail address: [email protected] (H. Hosny).
0305-4179/$36.00 # 2011 Elsevier Ltd and ISBI. All rights reserved.doi:10.1016/j.burns.2010.12.015
of recovery and/or improper splinting and physiotherapy. The
deformity is then aggravated by soft-tissue contracture that
finally ensues [3].
Surgical treatment is contemplated in those patients with
established contractural deformities in whom non-surgical
treatment is ineffective and performed when the scar tissue
becomes fully mature.
For elbow contractures, surgical treatment comprises
release of the contracture by incising the scar tissue and then
covering the resultant defect with one or more of various types
of tissue coverage including skin grafts, Z plasty, V–Y flaps,
729, Egypt.
Table 1 – Criteria of patients and results.
Case # Site Age(years)
Gender Tissue deficiency(cm)
Length added(cm)
Grafting Follow-up(months)
Complication
1 Elbow 22 F 8 10 � 6 –
2 Elbow 34 F 9 12 � 13 Venous congestion
3 Elbow 18 M 15 10 + 14 –
4 Elbow 42 M 7 9 � 9 –
5 Elbow 28 F 11 12 + 10 Partial graft loss
6 1st web 23 M 4.2 5.6 � 14 –
7 1st web 44 F 3.8 5 � 18 –
8 1st web 19 F 3.6 4.8 � 16 –
b u r n s 3 7 ( 2 0 1 1 ) 9 0 5 – 9 0 9906
local or distant fasciocutanous flaps, muscle or myocutanous
flaps and free flaps, each of them having its advantages and
disadvantages. The choice between them depends on the
availability of healthy skin near to the affected area.
Thumb contractures remain a very difficult issue in the
reconstructed hand that may involve shortening of the
adductor muscle in severe cases, necessitating the release
of its transverse head. In less severe cases, release can be done
using simple Z-plasty or better four-flap or five-flap Z-plasty.
The propeller flap was first introduced by Hyakusoku et al. in
1991 [4] to release burn contracture of the elbow, using the
scarred tissue. Shortly afterwards, some modifications to avoid
its shortcomings were added such as the multilobed propeller
flap [5], scar band rotation flap [6] and the pin-wheel flaps [7].
In this work, a new modification of the propeller flap is
proposed aimingat resolvingthe shortcomings of thepreviously
mentioned propeller flaps by decreasing their axis of rotation.
[()TD$FIG]Fig. 1 – Preoperative planning showing: (a) the calculation of the
plane of the arm (A) and forearm (F). In this case it is estimated
approximately 11 cm. (b and c) Anterior and lateral views of th
that the distance between the summits of the two lobes that wil
2. Patients and methods
This work involved eight patients, three males and five
females, with a mean age of 28.75 years (18–44 years) with
burn scar contracture deformities affecting the elbow (five
cases) and the hand 1st web space (three cases) (Table 1). The
scars were stable and mature with almost no healthy skin in
the vicinity. On the other hand, cases with joint disease,
immature scars or previously operated upon were excluded.
2.1. Preoperative planning
The flap design consists of a central subcutaneous pedicle and
eight triangular lobes based on a mathematically integrated
way. The length that needs to be added to compensate for the
shortening is calculated from the contralateral limb or along
amount of shortening by measuring through the midaxial
that after release of contracture; the defect will be
e 8-limbs of the modified propeller flap are then drawn so
l lie along the contracture should be 11 cm or slightly more.
[()TD$FIG]
Fig. 2 – (a) Preoperative calculations. (b) Planning for release of postburn thumb adduction deformity.
[()TD$FIG]
Fig. 4 – 10 days postoperative picture; some of the donor
areas of the triangular lobes have been closed in a V–Y
technique – 6 o’clock position – and others may need split
thickness skin grafting.
b u r n s 3 7 ( 2 0 1 1 ) 9 0 5 – 9 0 9 907
the mid-axial plain of the affected joint; thus the amount of
lengthening can be predetermined (Figs. 1 and 2). Then, the
flap is drawn so that the distance between the summits of the
triangular lobes that will fit along the axis of contracture
should be slightly longer than calculated lengthening to
compensate for any shortening that may occur to the flap
with rotation. The rotation of the flap is then carried out in 458
manner in either a clockwise or a counter-clockwise direction.
It is worth mentioning that the triangular lobes are random
flaps; hence, the height of the lobes should not exceed their
bases (ratio 1:1).
2.2. Technique
Incisions and release are then carried out, making sure that
dissection of the triangular flaps should include the subcuta-
neous tissue to insure maximum vascularity, taking into
consideration the fact that dissection should not go beneath
the central pedicle (Fig. 3). Then, the flap is rotated in the
planned direction, starting with the lobes adjacent to the
longitudinal axis of the contracture, followed by the rest of
the lobes. In some cases, when the tissues are lax, the
resultant V-shaped defects after release can be closed partly in
[()TD$FIG]Fig. 3 – Release of the contracture by incising deep down to
the deep fascia, the triangular lobes are elevated with the
subcutaneous tissue but avoiding the central pedicle.
a V–Y manner. This will facilitate closure of the donor sites by
the rotating lobes, obviating the need for skin grafts. On the
other hand, when the soft-tissue defect is extensive and
cannot be compensated for by the previous step, split-
thickness skin grafts are used to close the remaining defects
(Fig. 4). However, achieving full range of movement in the
affected joint is of utmost importance and should not be
compromised for not using skin grafts.
Postoperative care includes inspection of the flap in the
next day to insure its vascularity, followed by daily dressing
with an antiseptic solution. Stitches were removed after 10
days.
3. Results
In all cases, stable and supple tissue coverage was obtained
(Figs. 5 and 6) with a mean follow-up period of 12.5 months
(range 6–18 months). In the early postoperative period, no total
or partial losses of the flap had occurred. Only congestion at
the tip of one of the lobes was encountered in one flap that
might be attributed to decreased amount of its underlying
[()TD$FIG]
Fig. 5 – A case of postburn thumb adduction deformity: (a) preoperative view and (b) postoperative view.
[()TD$FIG]
Fig. 6 – Postoperative result showing supple coverage after
release of the contracture deformity.
b u r n s 3 7 ( 2 0 1 1 ) 9 0 5 – 9 0 9908
subcutaneous tissue. However, it resolved spontaneously after
few days. Partial loss of less than 20% of the skin graft in
another case of elbow contracture occurred, and was managed
conservatively (Table 1). All the cases ran a smooth postoper-
ative period and achieved full range of movement of the
affected joints. Physiotherapy was not needed, and no
recurrence has occurred in any of our patients during the
period of this work.
4. Discussion
In spite of modern advances in burn care in the acute stage and
use of early physiotherapy and splints, contractural deformi-
ties affecting the upper extremity still present to plastic
surgeons due to improper physiotherapy and/or acquiring the
position of comfort. These deformities represent a challenge
to reconstructive surgeons as they may significantly alter the
quality of patient’s life.
Surgical management of contractural deformities involves
incisional release of the scar tissue and subsequent coverage
of the resultant defect. Regarding the elbow, flap coverage is
preferred over skin graft, as the latter has the tendency to
contract and there is always the risk that the graft may not
take partially or totally. Moreover, flap coverage brings in well-
vascularised, elastic, often uninjured, tissue that will not
contract and provides an aesthetic and durable coverage.
To reconstruct a burn elbow contracture, numerous local
and distant flaps have been employed, such as V–Y and Z-
plasty techniques for linear band contractures [8], local
fasciocutaneous flaps that may or may not include previously
burned skin territories, radial, ulnar and posterior inteross-
eous fasciocutaneous proximally based flaps and reversed
flow flaps such as the lateral arm and the ulnar recurrent
upper-arm flap. In addition, distant pedicled and microvascu-
lar transfer flaps are being used [9]. In all these flaps, the
functional losses, cosmetic results and compromise of future
reconstructive options should be taken into consideration
when planning these surgeries.
The use of subcutaneous pedicled flaps for burn contrac-
tures has been employed with encouraging results [10,11], and
also it was the case when incorporating scarred tissue for
reconstructive surgery of extensive burns [12]. In 1991,
Hyakusoku et al. introduced the concept of propeller flap
consisting of two lobes. Later, it was followed by some
modifications to include more limbs, for example, the
multilobed propeller flap [4], and pin-wheel flap [6].
The previously mentionedpropeller flaps share the common
propertyof rotation ina908 fashion.Asa result, thismay include
the risk of twisting the pedicle and causing some vascular
compromise of the flap. Further, the flaps are confronted by the
anatomical boundaries that limit the length of the flap lobes to
maximallyhalf thecircumference of the limb, as the filling lobes
are always perpendicular to contracture axis.
The modification in this work is the design of eight lobes in
a mathematically calculated pattern that makes the rotation
in a 458 instead of 908. This has the benefit of making the filling
lobes – that will fit along the contracture axis – to be along an
axis that lies away from the joint axis. Further, decreasing the
size of the remaining V-shaped defects, so that some of them
may be closed as V–Y technique reducing the amount of skin
grafts if needed. Moreover, the rotation in a 458 reduces the
risk of twisting the central pedicle and reduces the inevitable
shortening that occurs with flap mobilization.
b u r n s 3 7 ( 2 0 1 1 ) 9 0 5 – 9 0 9 909
In this work, neither flap loss nor recurrence was
encountered. Only venous congestion of one of the lobes
was seen, probably because of deficient subcutaneous tissue
underneath, which resolved spontaneously, and partial loss of
skin graft that was managed conservatively.
Hence, the eight limb – 458 rotation – propeller flap has the
benefits of flexible easy design tailored to the magnitude of
contracture, less twist of the central pedicle because of less
rotation, not limited by anatomical or pathological restrains as
it is away from joint axis and can include scar tissue and, finally,
it is a one-stage procedure with minimal, if any, added donor-
site morbidity. Hence, we find it very useful in managing severe
burn contractures of the elbow and 1st web space, especially
when the surrounding skin is unhealthy with much scars.
Conflict of interest statement
The article, including related data, figures and tables has not
been previously published and the article is not under
consideration elsewhere.
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